MEDICARE: SHELBY EYECARE ASSOCIATES PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	4901003013	MI
2	152WX0102X	Occupational Vision Optometrist	4901003013	MI
3	152WP0200X	Pediatric Optometrist	4901003013	MI
4	152WS0006X	Sports Vision Optometrist	4901003013	MI
5	152WV0400X	Vision Therapy Optometrist	4901003013	MI
6	152W00000X	Optometrist	4901003013	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002109A	OTHER	MI	VSP GROUP NUMBER
2	P90472	OTHER	MI	BLUE CARE NETWORK

General Provider Information

NPI Number	:	1275588840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHELBY EYECARE ASSOCIATES PC

Provider Business Mailing Address
First Line	:	48187 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48317-3268
Country	:	US
Telephone Number	:	586-739-9550
Fax Number	:	586-739-0083

Provider Business Practice Location Address
First Line	:	48187 VAN DYKE AVE
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48317-3268
Country	:	US
Telephone Number	:	586-739-9550
Fax Number	:	586-739-0083

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MARIE DORAU
Credential	:
Telephone Number	:	586-739-9550

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	12/29/2010

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